CHIEF WARRANT OFFICER 4 ALEJANDRO CORONADO
Accident Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama

On an overcast, zero illumination night, an AH-64E crew departed the forward arming and refueling point. With the instructor pilot in the pilot’s (back) seat and the pilot, a Readiness Level 3 aviator, in the co-pilot gunner (front) seat, they headed to the range to conduct night familiarization gunnery. Tragically, before the end of the training event, both pilots would lose their lives in an avoidable mishap.

Sequence of events
Preparations for the aerial gunnery began weeks prior to the training event. The published operations order outlined the plan to conduct a helicopter gunnery to qualify new aviators through Table VI. The training’s secondary purpose was to conduct familiarization gunnery for newly assigned RL3 aviators to gain experience before an upcoming combat deployment. A waiver was submitted requesting deviation from published procedures to allow RL3 aviators to conduct gunnery tasks under day visual meteorological conditions, assessing these missions as an overall MODERATE risk.

On the day of the mishap, after completing the risk assessment, the IP assessed the mission as an overall LOW risk for a night familiarization fires. The IP was then briefed by the mission briefing officer, who also assessed the mission as LOW, before receiving final mission approval from a company commander. The LOW risk assessment and approval was made under the assumption that the approved waiver authorized the mission to be conducted as it was planned. However, the IP, MBO and company commander assessed the mission without reviewing the waiver. They didn’t understand the limitations the waiver placed on the mission and based their assessment on an assumption.

Following the mishap crew’s fifth engagement of the night, a diving fire rocket engagement, the IP in the pilot’s seat successfully executed the dive recovery and placed the aircraft in a left 47 degree bank to execute a 180 degree turn. During the turn, the CPG passed the battle damage assessment to the range tower, which then gave the sixth target handover. While the CPG was focused inside the aircraft copying the target handover — still in the left turn — the IP diverted his attention to something other than flying the aircraft. Immediately after, the nose started pitching down to approximately 9 degrees nose low and the descent rate began to build.

Near the 180 degree point in the turn, the nose had pitched down to 19 degrees nose low and the descent rate reached 4,900 feet per minute. Approximately three seconds later, the IP noticed the unusual attitude and attempted to arrest the descent without pulling the nose up. The aircraft impacted the ground in a nose-low, 11 degree left bank at a 3,900-feet-per-minute rate of descent and 127 knots, resulting in fatal injuries to the crew and destruction of the aircraft.

What can the Army do?

• Leaders must ensure waiver requests properly outline deviations from written procedures and risk mitigation factors are established to ensure the safe execution of the mission. Once the waiver request has been approved, ensure it is disseminated and understood by all personnel participating in the exercise.

• Leaders must ensure a risk assessment and risk mitigation has been conducted in accordance with the unit’s standard operating procedures and ATP 5-19, Risk Management, before briefing and/or approving any mission. They must also ensure restrictions and risk mitigation factors established by approved waivers are annotated in the risk assessment document and understood by participating personnel.

• Leaders must ensure aviators understand the importance of proper airspace surveillance and the hazards associated with distractions while flying.

• Leaders need to emphasize the importance of aircrew coordination principles during the execution of gunnery tasks, highlighting scenarios where one pilot is focused inside the aircraft.

• Leaders must reiterate to pilots in command and instructors the importance of controlling the sequence and timing of target handovers during gunnery tables, especially when maneuvering and operating with inexperienced crewmembers.